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Patient safety and quality of care in mental health: a world of its own? [Editorials]


Quality and safety in healthcare, as an academic discipline, has made significant progress over recent decades, and there is now an active and established community of researchers and practitioners. However, work has predominantly focused on physical health, despite broader controversy regarding the attention paid to, and significance attributed to, mental health. Work from both communities is required in order to ensure that quality and safety is actively embedded within mental health research and practice and that the academic discipline of quality and safety accurately represents the scientific knowledge that has been accumulated within the mental health community.

A Devil's dictionary for mental health [Editorials]


Clinical psychiatry, for all its emphasis on scientific rigour, is mediated mainly by words rather than by numbers. As with other professional areas, it has developed its own set of jargon words and phrases. Many of these are not the technical terms traditionally seen as jargon, but standard English words and phrases used in an idiosyncratic way. They therefore go unnoticed as jargon, while enfeebling our communications. I have used the template of Ambrose Bierce's The Devil's Dictionary to highlight some examples, with the aim of helping us all to talk, write and, perhaps, think more clearly.

Personality disorder services in England: findings from a national survey [Original papers]


Aims and method We aimed to evaluate the availability and nature of services for people affected by personality disorder in England by conducting a survey of English National Health Service (NHS) mental health trusts and independent organisations.

Results In England, 84% of organisations reported having at least one dedicated personality disorder service. This represents a fivefold increase compared with a 2002 survey. However, only 55% of organisations reported that patients had equal access across localities to these dedicated services. Dedicated services commonly had good levels of service use and carer involvement, and engagement in education, research and training. However, a wider multidisciplinary team and a greater number of biopsychosocial interventions were available through generic services.

Clinical implications There has been a substantial increase in service provision for people affected by personality disorder, but continued variability in the availability of services is apparent and it remains unclear whether quality of care has improved.

Perceptions and knowledge of antipsychotics among mental health professionals and patients [Original papers]


Aims and method To assess the patients' most influential concerns regarding long-acting injectable antipsychotics (LAIs) and mental health professionals' preconceptions about these concerns. For both groups, to assess the level of knowledge about LAIs. This cross-sectional study used semi-structured interviews of patients with schizophrenia or schizoaffective disorder (n = 164), nurses (n = 43) and physicians (n = 20).

Results The mental health professionals overestimated many of the patients' fears of LAIs, and the expressed fears exceeded the actual experiences of patients already on LAIs. Acceptance to switch to LAIs was associated with shorter time from diagnosis. Nurses and patients disclosed limited knowledge of antipsychotics.

Clinical implications Physicians and nurses should aim to identify the individual patient's concerns about LAIs in the discussion about choice of antipsychotic treatment early in the course of illness.

Mental capacity legislation in the UK: systematic review of the experiences of adults lacking capacity and their carers [Review Article]


Aims and method Capacity legislation in the UK allows substitute decision-making for adults lacking capacity. Research has explored the experiences of such adults and their carers in relation to the Adults with Incapacity (Scotland) Act 2000, and the Mental Capacity Act 2005 in England and Wales. A systematic review of the relevant research was performed using a framework method.

Results The legislation provided mechanisms for substitute decision-making which were seen as useful, but there were negative experiences. Decision-making did not always seem to follow the legislative principles. Awareness of the legislation was limited. Most research was qualitative and some was of low methodological quality. Data were too heterogeneous to allow comparisons between English and Scottish law.

Clinical implications Capacity legislation was generally viewed positively. However, some experiences were perceived negatively, and the potential benefits of the legislation were not always utilised.

Does the cognitive therapy of depression rest on a mistake? [Special articles]


Cognitive therapy for depression is common practice in today's National Health Service, yet it does not work well. Aaron Beck developed it after becoming disillusioned with the psychoanalytic theory and therapy he espoused and practised. But Beck's understanding of psychoanalysis appears to have been seriously flawed. Understood rightly, the psychoanalytic approach offers a cogent theory and therapy for depression which, unlike the cognitive approach, takes us to its emotional-motivational roots. A clinically successful therapy can afford to eschew theory and rest on its pragmatic laurels. This is not the case for cognitive therapy. The time is right to re-examine the psychoanalytic theory and treatment of depression.

The cognitive therapy of depression rests on substantial theoretical, empirical and clinical foundations: a reply to Dr Gipps [Special articles]


Dr Gipps claims that the cognitive therapy for depression rests on a mistake. But his anachronistic analysis of Beck's early research from the perspective of current psychoanalytic theory misses the point. The value of the research was not that it disproved psychoanalytic theory, but that it generated a model of depression that has revolutionised psychotherapy research. Psychoanalysts are belatedly adopting research methods that Beck pioneered half a century ago. The cognitive model of depression has explanatory power for both maintenance and vulnerability and has substantial research underpinning it. Cognitive therapy for depression has a larger body of evidence for its efficacy and relapse prevention effect than any other psychotherapy. Transference-focused approaches to depression have yet to establish themselves in the same way.

Suicide patterns on the London Underground railway system, 2000-2010 [Special articles]


Aims and Method Suicidal acts on underground railway networks are an area of public health concern. Our aim was to review recent epidemiological patterns of suicidal acts on the London Underground to inform future preventive interventions. Data from 2000 to 2010 were obtained from the British Transport Police via a Freedom of Information request.

Results The mean annual rate of suicidal acts from 2000 to 2010 was 5.8 per 100 million passenger journey stages. Of those who died by suicide, 77.3% were of White Northern European ethnicity. A fifth had a history of mental illness.

Clinical implications The widening gap between the number of recorded suicide attempts and completed suicides is encouraging. Further research is required regarding the role of drug and alcohol use, psychiatric history and area of residence. Installation of platform screen doors should be considered in future railway network expansion.

Psychiatric neurosurgery in the 21st century: overview and the growth of deep brain stimulation [Current Practice]


Ambulatory deep brain stimulation (DBS) became possible in the late 1980s and was initially used to treat people with movement disorders. Trials of DBS in people with treatment-resistant psychiatric disorder began in the late 1990s, initially focusing on obsessive–compulsive disorder, major depressive disorder and Tourette syndrome. Despite methodological issues, including small participant numbers and lack of consensus over brain targets, DBS is now being trialled in a wide range of psychiatric conditions. There has also been more modest increase in ablative procedures. This paper reviews these developments in the light of contemporary brain science, considers future directions and discusses why the approach has not been adopted more widely within psychiatry.

Teaching provision for old age psychiatry in medical schools in the UK and Ireland: a survey [Education & training]


Aims and method This work builds on a survey first done in 1999 to understand how old age psychiatry teaching is embedded in undergraduate medical schools in the UK and Ireland and the influence of academic old age psychiatrists on teaching processes. We invited deans of 31 medical schools in the UK and Ireland in 2015 to complete an online survey to reassess the situation 16 years later.

Results Response rate was 74%. As found in the original survey, there was variation across medical schools in how old age psychiatry is taught. Half of schools stated there was not enough space in the curriculum dedicated to old age psychiatry, and not all medical school curricula offered a clinical attachment. Medical schools that involved academic old age psychiatrists in teaching (59%) showed a greater diversity of teaching methods.

Clinical implications There is a need to recognise the importance of old age psychiatry teaching, with the consensus of opinion continuing to be that more curriculum space needs to be given to old age psychiatry. To achieve this we advocate increasing the number of old age psychiatrists with teaching roles, as relying on academics to teach and lead on curriculum development is challenging given their greater research pressures.

Corrections [Corrections]